L4: Allergic Rhinitis, Tinnitus, and Urticaria Flashcards
Define barotrauma.
Discomfort or damage due to pressure differences between the MIDDLE EAR and the outside world.
List 2 common causes of barotrauma.
Flying
Diving
List common sx associated with barotrauma.
pressure, pain, hearing loss, or tinnitus
What are common PE findings associated with barotrauma?
- Middle ear effusion
- Hemotympanum (blood in middle ear)
- Possible TM rupture
True or false: barotrauma typically heals on its own over time.
True
List the tx for barotrauma
- AVOIDANCE
- Oral or nasal decongestants
- Swallowing, valsalva, chewing gum, etc.
- Goal is to equalize middle ear pressure
Under what circumstance would you refer barotrauma to ENT?
If perilymphatic fistula present (vertigo and sensorineural hearing loss)
What kind of tumor is an acoustic neuroma?
Schwann cell tumor
*SLOW growing!
Where do acoustic neuromas derive from?
Vestibular portion of CN VIII
What is another name for an acoustic neuroma?
Vestibular Schwannoma
What is a classical presentation for acoustic neuroma?
Unilateral sensorineural hearing loss and tinnitus
+/- gait disctrubance or other CN nerve involvement
How do you dx an acoustic neuroma?
- Audiometry is best initial test
- Followed by MRI
- Important to r/o meningioma
Tx for acoustic neuroma?
- Surgery
- Radiation
- Observation
Define tinnitus
Perception of sound in one or both ears (buzzing, ringing, pulsatile, nonpulsatile)
What is tinnitus often an early indicator for?
Cochlear hair cell dysfunction or loss
What type of tinnitus is most commonly vascular in etiology?
Pulsatile (best to refer to ENT)
List some possible causes of tinnitus (6)
- Ototoxic meds (ex: aminoglycosides)
- Presbycusis (SN hearing loss w/ aging)
- Otosclerosis (fusion of ear bones)
- Vestibular Schwannoma
- Chiari malformations (issue with cerebellar tonsils or something)
- Barotrauma
How do you dx tinnitus
- Hx
- PE (complete head and neck exam, auscultate for bruitis in pts with possible vascular tinnitus)
- Refer to ENT if pulsatile
What is a common symptom associated with tinnitus you should be concerned about?
Anxiety and depression
What is the tx for tinnitus?
- MAIN GOAL IS TO LESSEN AWARENESS ON IMPACT AND QUALITY OF LIFE
- Behavioral therapy
- Benzodiazepines (Xanax)
- White noise masking devices
Define seasonal allergic rhinitis
- AKA “hay fever”
- Occurs at particular times of the year (trees, grass, ragweed)
Define perennial allergic rhinitis
- Occur year round
- Dust mites, cockroaches (ew), mold, animal dander
How do you differentiate between allergic rhinitis vs. vasomotor rhinitis
Allergic rhinitis will experience episodes of sneezing, rhinorhea, and nasal obstruction (often accompanied by itchy eyes, nose, and palate)
Vasomotor rhinitis is non-allergic (AKA perennial non-allergic)
What is the typical age of onset for allergic rhinitis?
< 30 years old (peak incidence in childhood/adolescence)
What does allergen exposure produce in regards to allergic rhinitis?
IgE antibodies
- These sensitize mast cells and basophils
- These cells then degrade and release inflammatory mediators (histamines)
List the 3 primary sx of allergic rhinitis (AR).
- Rhinorrhea (runny nose)
- Sneezing
- Nasal congestion
What is a v important risk factor for allergic rhinitis you should def know?
FAMILY HX OF ATOPY!!! Remember the atopic triad.
There’s others. But like know this one. (L4 slide 22)
List the 5 primary areas you should assess during a physical exam for allergic rhinitis
- Periorbital area
- Eyes (sx usually bilateral)
- Nose
- Throat
- Ears
What are the 2 common findings in the periorbital area associated with AR?
- ALLERGIC SHINERS: bluish purple rings around both eyes
- DENNIE-MORGAN LINES: skin folds under eyes consistent with allergic conjunctivitis
Big letters = buzz words ;-)
What PE findings might you find in the eyes for a pt with AR?
- Diffuse redness involving the bulbar and palpebral conjunctiva
- Tearing or clear watery discharge
- Chemosis (swelling)
- Eyelid edema
What PE findings might you find in the nose for a pt with AR?
- PALE, BOGGY, “BLUISH” MUCOSA *Buzz words baby!!!
- Clear discharge
- Nasal crease secondary to “allergic salute”
What PE findings might you find in the throat for a pt with AR?
- Post nasal drainage in posterior pharynx
- “Cobblestoning” (swollen LN tissue)
What PE findings might you find in the ears for a pt with AR?
Retracted TMs and/or serious otitis media (OME)
How do you diagnose AR?
- Clinical dx
- Allergy testing can be confirmatory but not necessary for initial dx
What are the 2 types of allergy testing that can be ordered?
Skin testing: scratch or prick skin testing
Serum testing: ImmunoCAP
What indicates a positive scratch (prick) test?
“wheal and flare” rxn with wheal size > or = to histamine control of 3mm
Which of the 2 allergy skin tests puts the patient at greatest risk for anaphylaxis?
Scratch test
Serum testing is less risk, but also less sensitive and more expensive
What is the general tx for AR?
- Avoidance of allergens
- Pharmacotherapy
- Immunotherapy
What are the pharmacotherapy options for AR?
- Oral or intranasal antihistamines
- INTRANASAL GLUCOCORTICOSTEROIDS!
- Sympathomimetics/decongestants
- Leukotriene receptor antagonists
What do 1st generation antihistamines help to alleviate in regards to AR? What do they not help with?
Help w/ sneezing, rhinorrhea, and itching
No help w/ nasal congestion
List two 1st generation antihistamines
-Chlorpheniramine (Chlor-trimeton)
-Diphenhydramine (Benadryl)
KNOW THESE NAMES PEOPLE. YOU CAN DO IT!
What are the side effects of 1st generation antihistamines?
SEDATION, dry mouth, constipation
What is a benefit of 2nd generation antihistamines?
LESS SEDATING, but no more effective otherwise
Name 3 2nd generation antihistamines.
- Loratadine (Claritin) QD
- Fexofedadine (Allegra) QD or BID
- Cetrizine (Zyrtec) QD
What is the mode of action for an antihistamine nasal spray?
H1 antagonist
List a benefit and side effect of antihistamine nasal spray
Benefit: Rapid onset; dose BID
Disadvantage: Tastes gross and bitter
*May be used alone or in combo with steroid nasal spray
What is the mode of action for cromolyn nasal spray?
Mast cell stabilizer
What is a disadvantage of cromolyn nasal spray?
Lower efficacy; needs frequent dosing
What is the LEAST RISKIEST med you can prescribe for a pt with allergic rhinitis?
Cromolyn nasal spray; no serious side effects :-)
Are oral antihistamines or nasal steroid sprays more effective?
Nasal steroid sprays
1st and 2nd generations available; lower bioavailability with second generation
What is a side effect of nasal steroid spray use?
Epistaxis (tell pt to point away from nasal septum)
How can leukotriene receptor antagonists (like Singulair) be used most efficiently for AR?
- LTRA are less effective than nasal steroid sprays
- LTRA + 2nd gen oral antihistamine provides more relief than either alone (synergism!)
What is other name for sympathomimetics?
Decongestants
When would you recommend a sympathomimetic (decongestant)?
If the pt has marked congestion despite antihistamine use. VASOCONSTRICTION will decrease edema and secretions
Name a sympathomimetic
Sudafed
Be careful; crazy ppl make meth with this lol
Patients with what medical conditions should you be cautious about prescribing a sympathomimetic (decongestant)?
- Hypertension
- Cardiac disease
Describe immunotherapy (what is it effective for, how is it given, how long does the tx take)
- Effective for tx of ALLERGIC conjunctivitis, rhinitis, and asthma
- Gradual administration of increasing amounts of allergen
- Can be given in subcutaneous or sublingual forms
- Requires multiple, regularly scheduled visits over a period of 3-5 years
What tx would you recommend for a patient <2 years old with AR?
- Cromolyn sodium nasal spray
- 2nd gen antihistamines (Cerizine (Zyrtec) approved for children > or = to 6 months)
What types of treatments would you recommend for a patient > 2 years old with MILD allergic rhinitis? (4 options)
- 2nd generation oral antihistamines (Claritin, Zyrtec, Allegra)
- Antihistamine nasal sprays (Azelastine, Olopatadine)
- Glucocorticoid nasal sprays (use for continuous or episodic AR 2-3 days prior to exposure)
- Cromolyn nasal spray (least effective)
What is the first line of treatment for a patient with MODERATE TO SEVERE allergic rhinitis? Why?
Glucocorticoid nasal sprays
- Most effective single agent
- Few side effects
- Many options (newer meds more convenient and safer for long term use)
Name the glucocorticoid nasal sprays recommended for children > or = to 2 years of age? (2)
- Mometasone (Nasonex)
2. Fluticasone furoate (Veramyst)
Name the glucocorticoid nasal spray recommended for children > or = to 4 years of age?
Fluticasone proportionate
Aside from glucocorticoid nasal sprays, what other treatments would you use for AR?
(these can be used as a second agent w/ the steroid nasal sprays)
- Antihistamine nasal spray
- Oral antihistamine
- Cromolyn nasal spray
- Montelukast (Singulair)
- Oral antihistamine/decongestant combo
What tx would you use for a pt with AR with concomitant asthma?
Montelukast (Singulair): provides useful additive therapy
What tx would you use for a pt with AR and allergic conjunctivitis? What 2 conditions should you avoid using this combo in?
-Steroid nasal spray + ophthalmic antihistamine drops
CAUTION: Avoid nasal steroid sprays in pts with glaucoma or cataracts!
When would you refer a pt with AR?
- If severe or refractory sx
- If AR and asthma; consider pulmonologist
- If recurrent sinusitis or otitis media; refer to ENT
What is another name for non-allergic rhinitis?
Vasomotor rhinitis
Also called perinneal non-allergic rhinitis
What is non-allergic rhinitis? What are the triggers?
- ABNORMAL AUTONOMIC RESPONSE
- Triggered by stress, sexual arousal (lol what?), perfumes, cigarette smoke, temperature changes
What are the primary sx of non-allergic rhinitis? What are the pertinent negatives that differentiate it from AR?
Primary sx:
- Nasal congestion
- Rhinorrhea
- and/or post nasal drip
Pertinent negatives:
-NO ocular/nasal itching or sneezing
What is the primary tx for vasomotor (non-allergic) rhinitis?
- Avoidance of triggers
- Nasal steroid sprays
- Antihistamine nasal sprays
- IPRATROPIUM NASAL SPRAY (anticholinergic)
- Use this if rhinorrhea is the prominent sx!
What specific tx would you recommend for a pt with vasomotor rhinitis whose primary complaint is rhinorrhea?
Ipratropium nasal spray (anticholinergic)
How would you describe a nasal polyp?
-Pedunculated (elongated stalk of tissue), non-tender, gray soft tissue growths
What is the primary sx of a nasal polyp?
Nasal congestion/obstruction
What condition’s might cause the presence of a nasal polyp?
- Allergic rhinitis
- Vasomotor rhinitis
- Chronic sinusitis
- Asthma (“Samter’s Triad”)
What is the tx for a nasal polyp?
Nasal steroid spray
Refer to ENT for obstructive sxs
What is the cause of rhinitis medicamentosa?
- Regular use of a decongestant nasal spray (ex: Afrin)
- > 3 days of use leads to rebound congestion (pts will increase frequency of use to obtain temporary relief; leads to dependency)
What would you see on PE w/ a patient who has rhinitis medicamentosa?
Erythematous and swollen mucous membranes
What is the tx for rhinitis medicamentosa?
- Discontinue Afrin
- Start steroid nasal spray
How would you describe urticaria (hives)?
Well circumscribed, intensely PRURITIC, raised wheals; PALE TO BRIGHT ERYTHEMA
+/- central pallor
What is the time length for acute urticaria?
present less than 6 weeks
What is the time length for chronic urticaria?
s/s recurring most days of the week for 6 weeks or longer
How long does an individual urticaria lesion last?
Disappear within 24 hours
Lesions are TRANSIENT
What is the cause of urticaria?
- Release of histamines from cutaneous MAST CELLS of superficial epidermis
- Can be accompanied by angioedema
What are some common causes of urticaria?
- Infections
- Allergic rxn to meds
- Foods (milk, eggs, shellfish, etc.)
- Insect/bee stings
- Direct mast cell activation (morphine, codeine, etc.)
- NSAIDs
How do you dx urticaria?
-Clinical dx based on H&PE (past hx of hives, signs and sx of anaphylaxis, new foods or meds, insect bite, etc.)
What is urticaria easily confused for? What are the sx?
Urticarial vasculitis:
- Fixed (lasting longer than 24 hours) erythematous, painful, urticarial plaques with blanching halos
- Leaves residual hyperpigmentation or purpura
- Linked with SLE
What is the tx for urticria
-H1 HISTAMINE BLOCKER (2nd generation) are the preferred first line-therapy
Can also use:
- H2 histamine blocker in combo with H1
- Ranitidine (Zantac), famotidine (Pepcid), Cimetiidine (Tagament)
- Use oral glucocorticoids if angioedema or persistent sx
Why do we prefer 2nd generation H1 histamine blockers?
- Minimal sedation
- No anticholinergic effects
- Few drug-drug interactions
- Less frequent dosing
Name 2 H1 histamine blockers
-Certizine (Zyrtec)
-Levocetirizine (Xyzal)
These 2 may be more affected due to mast cell-stabilizing properties
Who is the Assistant to the Regional Manager?
Dwight K. Schrute YOU IDIOT
